The rise of HIV in Madagascar

By Kristen Negrotti

A typical rural healthcare centre

Amidst declining infection rates and international funding, HIV/AIDS in sub-Saharan Africa has fallen off the global radar, leaving Madagascar ill-equipped to face a potential crisis. Once believed to be relatively unscathed by the HIV/AIDS epidemics of neighbouring countries, Madagascar is now experiencing skyrocketing rates of HIV infection. Despite an HIV incidence rate of 0.18 per 1,000 people, the number of people living with HIV in Madagascar has increased by at least 54% since 2010, according to the UNAIDS Data 2017 report. Of this HIV-positive population, only 8% are aware of their status, the lowest rate in the world.

In the Anosy region, where 91% of women and 94% of men have never been tested for HIV, the threat of this disease is amplified. The Mexico City Policy, combined with wider declines in donor support, have contributed to a desperate shortage in sexual and reproductive health (SRH) services. Certain NGOs have left the region completely, whilst others now face stock-outs of crucial resources such as condoms and sexually transmitted infection (STI) testing materials.

Pervasive poverty and devastatingly low education levels exacerbate these risk factors. In general, children who do not complete primary school are over twice as likely to contract HIV as children who continue their schooling. Since 37.7% of youth aged 11 to 14 in Anosy have never attended school, this indicates that many of the region’s young people are vulnerable to the disease. Moreover, over 96.7% of Anosy residents live below the poverty line, which can contribute to a range of HIV risk factors, including transactional sex, early marriage, and migration. These issues translate into low levels of SRH knowledge and risky practices, which compound the threat of HIV/AIDS in the Anosy region. Less than 40% of residents are able to name key HIV prevention methods such as having one monogamous HIV-negative partner, whilst a mere 5% of females and 8% of males aged 15 to 19 report using condoms. These gaps have contributed to alarmingly high rates of STIs; according to basic healthcare centre (CSB) data from the regional capital of Fort Dauphin, 8.2% of pregnant women test positive for syphilis.

The terrible road conditions make it difficult to get health supplies to rural communities

In Anosy’s most rural areas, these risk factors are magnified. The fokontany (village clusters) of Mahatalaky, Sainte Luce, and Tsagnoriha face particularly limited health services, with only one doctor serving 12 villages spread over considerable distances. Definitive testing and treatment for HIV are only available hours away at regional hospitals, making necessary medical care inaccessible for many rural community members. Faced with regular population migration and reportedly low condom usage, the under-resourced CSBs at these rural sites are unprepared to address the growing SRH challenges in these communities.

In April 2019, SEED Madagascar launched Project Mitao (‘to protect yourself’ in Malagasy) to generate a deeper understanding of HIV/AIDS and sexual and reproductive health and rights (SRHR) more widely. Supported by the Mercury Phoenix Trust and private donors, Project Mitao seeks to address this growing crisis through collaborative health research on the complex factors driving the spread of HIV and local capacity-building to promote prevention and treatment. Operating across Mahatalaky, Tsagnoriha, and Sainte Luce, this project will bring together a variety of stakeholders – from government officials and healthcare providers to the most at-risk youth – to drive a situational analysis of HIV/AIDS and SRHR. Targeted education with both students and out-of-school youth will cover important SRHR topics like puberty, consent, STIs and HIV/AIDS, and contraception. This combination of this education with participatory, community-driven research will immediately alleviate knowledge gaps whilst improving coordination amongst stakeholders to address SRHR in these sites. Ultimately, Project Mitao will produce the knowledge needed to ensure that HIV/AIDS receives the necessary response on both the national and international levels.